NHA CBCS flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Clean claim

A claim containing all required data elements, correctly formatted, that a payer can adjudicate without requesting additional information or correction.

CMS-1500 form

The standard paper claim form used by noninstitutional providers such as physicians and suppliers to bill Medicare and most commercial payers.

UB-04 form

The standard institutional claim form (CMS-1450) used by hospitals, skilled nursing facilities, and other facilities to bill payers.

Timely filing limit

The maximum period, set by payer contract or regulation, within which a claim must be submitted to be eligible for payment.

Coordination of benefits

The process that determines which of a patient's multiple insurance plans pays first as primary and which pays secondary.

NCCI edit

A payer edit pair that bundles a Column 2 code into a Column 1 code; modifier indicator 0 blocks override and indicator 1 permits one.

Global surgical package

A bundled payment covering preoperative, intraoperative, and postoperative services for a defined period after a surgical procedure.

Modifier 25

A modifier appended to an evaluation and management service to indicate a significant, separately identifiable service on the same day as a procedure.

Modifier 59

A modifier used to identify a distinct procedural service that would otherwise be bundled with another service under payer edits.

Redetermination

The first level of Medicare claim appeal, reviewed by the Medicare Administrative Contractor that processed the original claim.

Rejected claim

A claim returned unprocessed because of a data or formatting error, such as a missing identifier, rather than a coverage decision.

Denied claim

A claim a payer processed and refused to pay; the decision carries appeal rights and a stated reason code.

Claim scrubber

Software that checks claims for missing data, invalid codes, and payer-specific rules before submission to prevent rejections.

Remittance advice

A payer document or electronic file reporting how each claim line was adjudicated, including paid, denied, and adjusted amounts.

ERA 835 transaction

The electronic remittance advice standard that transmits payment and adjustment data to the practice for automated posting.

Explanation of benefits

A statement, often sent to the patient, showing services billed, the allowed amount, payer payment, and remaining patient responsibility.

Allowed amount

The maximum amount a payer will recognize for a service, typically the lesser of the billed charge or the contracted fee schedule.

Contractual adjustment

The difference between the provider's billed charge and the payer's allowed amount, written off and not billed to the patient.

Patient responsibility

The portion of the allowed amount the patient owes, consisting of copay, coinsurance, and any unmet deductible.

Copayment

A fixed dollar amount the patient pays for a covered service, often collected at the time of the visit.

Coinsurance

A percentage of the allowed amount that the patient pays after the deductible is met, such as 20 percent.

Deductible

The amount a patient must pay out of pocket for covered services before the health plan begins paying its share.

Payment posting

Recording payer payments and adjustments to patient accounts, then transferring any remaining balance to patient responsibility.

Aging report

A report grouping unpaid account balances by age, such as 0 to 30, 31 to 60, and 61 to 90 days.

CARC

The Claim Adjustment Reason Code explaining why a payer paid less than billed or denied a claim line.

RARC

The Remittance Advice Remark Code providing supplemental explanation about an adjustment or denial on a remittance.

Overpayment refund

Returning money received above the allowed amount; Medicare overpayments must be reported and returned within 60 days.

Patient statement

A bill sent to the patient after insurance adjudication showing the balance due and payment due date.

Self-pay account

A patient account with no insurance coverage, where the full charge is billed directly to the patient.

Point-of-service collection

Collecting copays, coinsurance, or deposits at the time of service to reduce later patient balances and bad debt.

Accounts receivable days

A measure of how long claims take to be paid, calculated as total receivables divided by average daily charges.

Write-off

An amount removed from the patient account balance because it is uncollectible or contractually not billable.